NOTE: The individual who directed you to this registration form should have provided you with their "Group ID". If you did not receive this please find out the appropriate code before registering your Practice to help us organize our groups.

Group ID:
*

Please select one

Account MGR:
*

Account MGR Phone:
*

-
Area Code Phone Number

Account MGR e-mail
*

Please select which services are being requested.

Toxicology (Urine)
*

YES NO

Pharmacogenomics
*

YES NO

Blood Wellness
*

YES NO

Hereditary Cancer
*

YES NO

Toxicology (oral)
*

YES NO

Finger Prick Allergy
*

YES NO

Will the practice be using MEBO?
*

Yes please No thank you What's MEBO?

MEBO is a user friendly software program used via table (iPad) at the practice by the patient that will see if they are eligible/qualified for a PGX and or Hereditary Cancer Genetic Test.** HIGHLY RECOMMENDED

Please estimate the monthly volume the best you can so the lab can forcast supply orders.